NUR 414 Review

The client is admitted for left heart failure. Which signs and symptoms correlate with this medical condition? 1. Orthopnea 2. Crackles in bilateral bases 3. Restlessness 4. Hepatomegaly 5. Peripheral edema

1,2,3

The nurse is caring for a client with myasthenia gravis. The nurse expects which test to be ordered to differentiate a myasthenic crisis from a cholinergic crisis? 1.) Edrophonium chloride 2.) Lumbar puncture 3.) CBC 4.) Magnetic resonance imaging (MRI)

1

A client has the rhythm below. (V-fib) What intervention is the priority? 1. Elective cardioversion 2. Immediate defibrillation 3. Administer Digoxin IVPB 4. Administer Adenosine IVPB

2

The nurse is assessing a client diagnosed with cellulitis of the upper left arm. Which manifestations should the nurse anticipate finding with this client? Select all that apply. 1. Deep, firm, painful nodule 2. Fever 3. Erythema 4. Pain 5. Purulent drainage

2,3,4

The nurse is admitting an 8-month-old infant with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that should be taken. 1. Monitor for signs of increased ICP 2. Institute respiratory isolation 3. Assist with a lumbar puncture 4. Insert an intravenous access device 5. Administer the prescribed antibiotics

2,4,3,5,1

An electrocardiogram (ECG) is prescribed for a client who reports chest pain. What early finding does the nurse expect on the lead over the infarcted area? 1. Inverted P waves 2. Flattened T waves 3. Elevated ST segment 4. Absence of P waves

3

A nurse mixes a short-acting and an intermediate-acting insulin in the same syringe to administer to a client with diabetes. List the actions in the order the nurse should perform them. 1.) Put air into the short-acting insulin vial 2.) Withdraw the prescribed amount of short-acting insulin 3.) Withdraw the prescribed amount of intermediate-acting insulin 4.) Put air into the intermediate-acting insulin vial

4,1,2,3

A client is admitted to the hospital with a diagnosis of emphysema and dyspnea. The nurse should encourage the client to assume what position? A. Orthopneic B. Supine C. Semi-Fowler D. Lithotomy

1

The nurse, caring for a 3-year-old child with meningitis, should be alert for which signs and symptoms of increased intracranial pressure? Select all that apply. 1. Irritability 2. Headache 3. Vomiting 4. Hypotension 5. Tachypnea

1,2,3

How does donepezil reduce the symptoms for clients with mild to moderate Alzheimer's disease? A. Anti-oxidating free radical B. Enhancing acetylcholine function C. Inhibiting serotonin uptake D. Reducing GABA action.

2

A patient diagnosed with hepatitis develops splenomegaly. When reviewing the laboratory report, which of the following results will the healthcare provider anticipate? 1.) Leukocytosis 2.) Polycythemia 3.) Thrombocytopenia 4.) Neutrophilia

3

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. What should the nurse monitor the client for? 1.) Hypoglycemia 2.) Tachycardia 3.) Ecchymosis 4.) Hyperkalemia

4

The nurse reviews the health record of a client with coronary artery disease (CAD). When assessing client risk, which elevated lab value is the most likely to cause the progression of CAD? 1. Microalbuminuria 2. Blood glucose 3. High-density lipoproteins 4. Low-density lipoproteins

4

A 2-year-old child admitted with a diagnosis of cellulitis was administer antibiotics and fluids. The child's temperature increased until it reached 103 F. When notified, the health care provider determined that there was no need to change treatment, even though the child had a history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurological impairment. Legally, who is responsible for the child's injury? 1. Nurse, because failure to further question the health care provider about the child's status placed the child at risk 2. Health care provider, because of total responsibility for the child's health and treatment regimen 3. Neither, because high fevers are common in children and the health care provider had little cause for concern 4. Health care provider, because this decision took precedence over the nurse's concern

1

A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the fluid and is concerned about the need for special care. What should the nurse advise the client? 1.) Take oral medication, drink fluids, and monitor capillary glucose levels 2.) Delay taking the medication until tolerating food, and call the office the next day 3.) Avoid food, drink clear liquids, take the daily medications, and stay in bed 4.) Skip the oral hypoglycemic pill, drink plenty of fluids, and rest

1

A client with type 1 diabetes is diagnosed with diabetic ketoacidosis and initially treated with IV fluids followed by an IV bolus of regular insulin. The nurse anticipates that the HCP will prescribe a continuous infusion of: 1.) Novolin R insulin 2.) Novolin U insulin 3.) Novolin N insulin 4.) Novolin L insulin

1

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). Which instruction does the nurse use when teaching the client about breathing techniques for COPD? A. "Use your abdomen when you breathe." B. "Inhale longer than you exhale." C. "Exhale through your nose." D. "Use deep rapid breathing."

1

A nurse is admitting a 2-year-old toddler who ingested half of a bottle of aspirin tablets to the emergency department. What acid-base imbalance is the client at risk for? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Respiratory acidosis

1

A nurse is caring for a 9-month-old infant who has been admitted to the pediatric unit with a tentative diagnosis of meningitis. A lumber puncture is performed. What is the most appropriate explanation to the parents for the purpose of the procedure? 1. Determine the causative agent 2. Measure the spinal fluid glucose level 3. Reduce the intracranial pressure 4. Identify the presence of blood

1

A nurse is caring for a client who has been taking several antibiotic medications for a prolonged time. Long-term antibiotics interfere with the absorption of fate. What order should the nurse anticipate? 1. water-soluble forms of vitamins A & E 2. High-fat diet 3. Total parenteral nutrition (TPN) 4. Supplemental cod liver oil

1

A nurse notes a client's respiratory rate is 24 breaths/min. on 3 L/min. of oxygen. The client reports shortness of breath. Which action does the nurse perform first? A. Perform a respiratory assessment. B. Notify the health care provider. C. Increase the oxygen flow rate. D. Administer Albuterol as prescribed.

1

The family member of a client with newly diagnosed Guillain-Bare Syndrome comes out to the nurse's station and informs the nurse the client states he is having difficulty breathing. What is the first action the nurse should complete? 1.) inform the family member the nurse will be in to assess the client 2.) Call a code, as the client will need endotracheal intubation 3.) Assure the family member this is a normal response for this disease 4.) Notify the health care provider

1

The nurse is caring for a client with heart failure. The client is scheduled to receive lisinopril and carvedilol in the next 30 minutes. The UAP reports the following vital signs to the nurse: Temperature of 98.9, heart rate of 52, respiration rate of 18, and blood pressure of 136/72. What is the most appropriate action for the nurse? 1. Administer the lisinopril but hold the carvedilol and notify the HCP 2. Hold both the lisinopril and the carvedilol and notify the HCP 3. Administer the lisinopril and carvedilol as scheduled 4. Administer the carvedilol but hold the lisinopril and notify the HCP

1

The nurse is providing discharge instructions to a client who is recovering from an acute case of viral hepatitis. Which statement by the client indicates a need for further education? 1.) I will take acetaminophen for pain 2.) I will be sure to take naps throughout the day 3.) I will eat small frequent meals 4.) I will avoid alcohol

1

What feeding instruction should a nurse give the mother of a 2-month-old infant with the diagnosis of heart failure? 1. Feed slowly while allowing time for adequate periods of rest 2. Refrain from feeding until crying from hunger begins 3. Use double-strength formula 4. Avoid using a preemie nipple

1

What should the nurse emphasize when teaching insulin self-administration to a 10-year-old child with recently diagnosed diabetes? 1.) The need to wash the hands before preparing the insulin injection 2.) The need to alternate the sites of the insulin injections among the four extremities 3.) The need to rub the injection site briskly for half a minute after giving the injection 4.) The need to shake the bottle of insulin thoroughly before drawing up the dose

1

When caring for a patient diagnosed with viral hepatitis, the healthcare provider experiences a needle stick with a contaminated needle. Which of the following actions should the healthcare provider do first? 1.) Wash the area thoroughly with soap and water 2.) Report to the emergency room 3.) Contact employee health so antiretrovirals can be started 4.) Place the needle in a biohazard bag for testing

1

Which statement by a client with type 2 diabetes indicates to the nurse that additional teaching about the diet is needed? 1.) I can eat as much dietetic fruit as I want 2.) I know that hard of my diet should be carbohydrates 3.) I need to reduce the amounts of saturated fats in my diet 4.) I can have a lettuce salad whenever I want it

1

a 7-year-old boy who is about to have an intravenous line inserted for antibiotics cries out that he is afraid of IVs. What is the nurse's most therapeutic response? 1. Tell me what frightens you 2. You're a big boy; this will hardly hurt 3. Come on - there's no reason to be afraid 4. It's just a little prick in the arm

1

A health care provider determines that a client has Myasthenia Gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply. 1.) Difficulty swallowing saliva 2.) Drooping of the upper eyelids 3.) Double vision 4.) Problems with cognition 5.) Intention tremors of the hands 6.) Non-intention tremors of the extremities

1,2,3

A client is admitted for respiratory distress and suspected pneumonia. Which assessment findings consistent with this diagnosis require continued monitoring? A. Chest pain with inspiration B. Dyspnea with ambulation C. Temperature 101.4 °F (38.56 °C) D. Blood pressure 109/78 mmHg E. Respiratory crackles and wheezes

1,2,3***``````````````````````````````````````````````````````````

A client with Guillain-Bare Syndrome has a feeding tube for nutrition. What priority actions should the nurse perform prior to starting the tube feeding? Select all that apply. 1.) Raise the head of bed to 30 degrees 2.) Assess the client's bowel sounds 3.) Don sterile gloves 4.) Check the tube placement 5.) Check the client's gastric residual

1,2,4,5

A patient with late-stage cirrhosis develops portal hypertension. Identify the potential complications below. Select all that apply. 1.) Esophageal varices 2.) Ascites 3.) Elevated serum albumin levels 4.) Left arm blood pressure reading of 160/80 5.) Splenomegaly

1,2,5

Which factors are associated with developing Guillain-Bare Syndrome? Select all that apply. 1.) Recent flu vaccination 2.) Recent upper respiratory infection 3.) Diabetes 4.) Client is 4-years-old 5.) Epstein-Barr infection

1,2,5

A nurse cares for a client whose endotracheal tube is being removed after successful weaning off mechanical ventilation. Which immediate post-extubation action(s) does the nurse perform? Select all that apply. A. Monitor continuous pulse oximetry. B. Position the client in the side-lying position. C. Auscultate breath sounds frequently. D. Administer oxygen at 2 liters per minute (LPM). E. Encourage the client to take small sips of water

1,3

An older client is admitted to the hospital with the diagnosis of dementia of the Alzheimer type and depression. Which signs of depression does the nurse identify? Select all that apply. A. "I don't know" answers to questions B. Loss of memory C. "I can't remember" answers to questions D. Decreased appetite E. Neglect of personal hygiene

1,3,4,5 Neglect of personal hygiene is associated with depression because of low self-esteem. People who are depressed do not have physical or emotional energy; "I don't know" and "I can't remember" answers require little thought or decision-making. Patients with depression can either have decreased or increased appetite. Depression does not cause memory deficits.

What methods support cognitive ability in clients with Alzheimer dementia? Select all that apply. A. Using calendars, clocks, and pictures to support memory B. Administering prescribed rivastigmine to the client with severe Alzheimer dementia C. Providing a limited number of choices to support decision making D. Quizzing the client regularly to assess orientation to person, place, and time E. Encouraging caregivers to support protected independence

1,3,5 (Strategies that assist orientation without challenging the client and that encourage safe independence and decision-making support cognitive function in Alzheimer disease, such as clocks, calendars, limited number of choices, and allowing safe independence. Interactions that quiz or challenge the client are not well tolerated and do not support cognitive functioning. Alzheimer dementia is characterized by cerebral atrophy and by the presence of neurofibrillary tangles and amyloid plaques. Rivastigmine is a cholinesterase inhibitor that provides a modest short-term cognitive benefit for some people with mild to moderate Alzheimer dementia. It works by increasing acetylcholine at cholinergic synapses. It is not approved for people with severe disease.)

A nurse caring for a client with uncontrolled diabetes suspects that a client is experiencing hypoglycemia in response to insulin administration. What clinical manifestations lead the nurse to this conclusion? Select all that apply. 1.) headache 2.) extreme thirst 3.) Increased urination 4.) Profuse sweating 5.) Confusion

1,4,5

The nurse is caring for a client who is scheduled to have a percutaneous liver biopsy. Which findings warrant the postponement of the procedure? Select all that apply. 1.) Ecchymosis and purpura 2.) Platelet count of 160,00/mm3 3.) Hepatic cirrhosis 4.) Marked ascites 5.) Hemoglobin less than 9 g/dL

1,4,5

A 13-year-old child with type 1 diabetes is receiving 15 units of Novolin R insulin and 20 units of Novolin N insulin at 7 am each day. At what time should the nurse anticipate a hypoglycemic reaction from the Novolin N to occur? 1.) During the evening 2.) In the afternoon 3.) Before noon 4.) Within 30 minutes

2

A client is admitted to the coronary care unit with atrial fibrillation and a rapid ventricular response. The nurse prepares for cardioversion. What nursing action is essential to avoid the potential danger of including ventricular fibrillation during cardioversion? 1. Energy level is set at its maximum level 2. Synchronizer switch is in the "on" position 3. Skin electrodes are applied after the T wave 4. Alarm system of the cardiac monitor is functioning simultaneously

2

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure? 1.) Keeping the client in the Trendelenburg position for at least 2 hours 2.) Maintaining the client in the supine position for several hours 3.) Encouraging the client to ambulate every hour for at least 6 hours 4.) Placing the client in the high-Fowler position immediately after the procedure

2

A client with Guillain-Bare syndrome has been hospitalized for three days. Which assessment finding indicates a need for more frequent monitoring? 1.) Hyperactive reflexes 2.) Ascending weakness 3.) Skin desquamation 4.) Localized seizures

2

A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. What is a priority nursing action during the first 48 hours after the client's admission? 1.) Determine the client's reasons for drinking 2.) Monitor the client's vital signs 3.) Increase the client's fluid intake 4.) Improve the client's nutritional status

2

A client with a 5-year history of myasthenia graves is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. The nurse expects what client response? 1.) Strength improves immediately after meals 2.) Strength decreases with repeated muscle use 3.) Weakness improves with muscle use 4.) Weakness decreases after hot baths

2

A nurse enters the room of a client with myasthenia graves and identifies that the client is experiencing increased dysphagia. What should the nurse do first? 1.) Perform tracheal suctioning 2.) Raise the head of the bed 3.) Administer oxygen 4.) Call the health care provider

2

A nurse is caring for a client with the diagnosis of Guillain-Bare syndrome. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention? 1.) Administer oxygen via nasal cannula 2.) Suction the client's oropharynx 3.) Place the client in the orthopneic position 4.) Auscultate for breath sounds

2

A nurse provides oral care for a client who is mechanically ventilated. What is the best rationale for providing this care? 1. Routine oral care may reduce the risk of tooth decay. 2. Routine oral care may reduce the risk of pneumonia. 3. The client is fully dependent on the nurse's actions. 4. The client's oral cavity requires regular moisture.

2

During nursing report, you learn that the patient you will be caring for has Guillain-Bare Syndrome. As the nurse, you know that this disease tends to present with: 1.) Signs and symptoms that are symmetrical and ascending that start in the upper extremities 2.) Signs and symptoms that are symmetrical and ascending that start in the lower extremities 3.) Signs and symptoms that are asymmetrical and ascending that start in the upper extremities 4.) Signs and symptoms that are unilateral and descending that start in the lower extremities

2

The nurse cares for a client with type 1 diabetes mellitus. The nurse finds the client shaky, light-headed, and weak with a blood sugar of 61 mg/dL. Which intervention is the best choice for this client? 1.) Administer 1 mg of glucagon subcutaneously 2.) Provide a half-cup of fruit juice to drink 3.) Infuse 50% dextrose intravenously 4.) Provide a slice of peanut butter toast to eat

2

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive disease (COPD) about the importance of assessing for right-sided heart failure after discharge. The nurse instructs the client to assess for: 1. Clubbing of the nail beds 2. Weight gain 3. Hypertension 4. Increased appetite

2

The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. What is the best term to describe this situation? A. Aphasia B. Agnosia C. Amnesia D. Apraxia

2

What does the nurse understand that clients with myasthenia graves, Guillain-Bare syndrome, and amyotrophic lateral sclerosis (ALS) share in common? 1.) Deficiencies of essential neurotransmitters 2.) Increased risk of respiratory complications 3.) Progressively deterioration until death 4.) Involuntary twitching of small muscle groups

2

What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type? A. Restricting gross motor activity B. Managing the client's unsafe behaviors C. Keeping the client oriented to time. D. Preventing further deterioration

2 Clients with Alzheimer disease require external controls to minimize the danger of injury caused by lack of judgment. The staff should not prevent all gross motor activity; the client needs to use the muscles, or atrophy will occur. Further deterioration usually cannot be prevented in this disorder with nursing interventions; donepezil may help delay deterioration in some clients. It may not be possible to keep the client continuously oriented.

A 70-year-old retired man has difficulty remembering his daily schedule and finding the right words to express himself. He is found to have dementia of the Alzheimer type. What symptoms are included in this disorder? A. Begin after a loss of self-esteem B. Demonstrate a progression of disintegration C. Occur fairly rapidly D. Have periods of remission

2 Dementias, such as that of the Alzheimer's type, result from pathological changes of CNS cells producing deterioration that is long term and progressive. These changes involve cognitive, functional and behavioral changes that reflect predictable stages.

A 12-year-old child with type 2 diabetes is scheduled for abdominal surgery. Which factors are the most important for the nurse to consider during the postoperative period? Select all that apply. 1.) Infection will likely occur at the surgical site 2.) The blood glucose level will increase because of the stress of surgery 3.) Diabetic control is usually maintained with insulin after surgery 4.) Ketoacidosis frequently occurs later in the postoperative period 5.) Urine test results are the most useful gauge of diabetic control after surgery

2,3

A client with ascites has a paracentesis, and 1500 mL of fluid is removed. The nurse recognizes that it is important to monitor the client for what signs of complications that may occur immediately after the procedure? Select all that apply. 1.) Temperature of 100.1 2.) Blood pressure of 90/40 3.) Heart rate of 110 4.) Hypoactive bowel sounds 5.) Pulmonary congestion

2,3

The nurse is performing a health history for a new client in the clinic. Which should the nurse identify as a risk factor for cellulitis in an adult? Select all that apply. 1. Scarlet fever 2. Peripheral vascular disease 3. Diabetes mellitus 4. Obesity 5. Hypertension

2,3,4

Which of the following are risk factors for Alzheimer's disease? Select all that apply. A. Increased serum calcium B. Father and Aunt had Alzheimer's disease C. Advancing age D. Previous head trauma E. Use of aluminum products

2,3,4

The client is admitted with suspected pneumonia. Vital signs include: temperature of 101.2, heart rate 112, respirations 24, blood pressure 130/78 and oxygen saturation of 95% on 3L NC. The client has the following on the heart monitor. Which intervention(s) should the nurse implement? Select all that apply. 1. Administer the PRN Adenosine 2. Administer the PRN Acetaminophen 3. Promote the use of the incentive spirometer 4. Administer the initial dose of Ceftriaxone IVPB 5. Encourage the client to drink fluids

2,3,4,5

The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? Select all that apply. 1.) Soak the feet in warm water daily 2.) Dry between the toes after bathing 3.) Remove corns as soon as they appear 4.) Wear shoes when out of bed 5.) Use a heating pad when the feet feel cold

2,4

A 40-year-old male is prescribed Metformin XL (Glucophage) to control his type 2 diabetes mellitus. Which statement made by this client indicates the need for further education? 1.) I will notify my doctor if I develop muscular or abdominal discomfort 2.) I must swallow my medication whole and not crush or chew it 3.) I will stop taking metformin for 24 hours before and after having a test involving dye 4.) I will take the drug with food

3

A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication? 1. Lidocaine 2. Alprazolam 3. Aspirin 4. Meperidine

3

A client is admitted to the hospital with ascites. The client reports a quart of vodka in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? 1.) Why do you mix the vodka with orange juice? 2.) Do you also eat when you drink? 3.) When was your last drink of vodka? 4.) What prompts your drinking episodes?

3

A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia Gravis is diagnosed and an anticholinergic medication is prescribed. The nurse is planning care with the client and spouse. What instruction is the priority? 1.) Perform range-of-motion exercises 2.) Eat foods that are pureed 3.) Take the medication according to a specific schedule 4.) Take a stool softener daily

3

A client is orally intubated and mechanically ventilated due to respiratory failure. Which item does the nurse ensure is kept next to the client's bed at all times? A. An endotracheal tube B. Arterial blood gas kit C. Bag valve mask device D. Tracheostomy kit

3

A client is receiving antibiotics and anti-fungal medications for the treatment of recurring cellulitis. What should the nurse encourage the client to do to compensate for the effect of these medications? 1. Take a multivitamin daily 2. Drink more fruit juices daily 3. Eat yogurt daily 4. Avoid spicy foods

3

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs? A. PaO2 of 93 B. No secretions when the client is suctioned C. Increased restlessness D. Skin warm and dry

3

A client undergoes cardiac catheterization via the femoral artery. What is the most important action after the procedure? 1. Elevate the head of bed 2. Keep the patient NPO 3. Assess the groin for bleeding 4. Check for a pulse deficit

3

A client with esophageal varices is admitted with hematemesis and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. What action should the nurse complete first? 1.) Assess the pain further 2.) Obtain the vital sings 3.) Stop the transfusion 4.) Monitor the hourly urinary output

3

A health care provider prescribes peak and trough levels of an antibiotic for a client who is receiving vancomycin intravenous piggyback (IVPB). The medication is scheduled for 0900 and will take an hour to infuse. When should the nurse have the laboratory obtain a blood sample to determine a peak level of the antibiotic? 1. 8:55 am 2. 9:30 am 3. 10:45 am 4. 11:45 am

3

A nurse is caring for a client with ascites who is to receive intravenous (IV) albumin. What changes should the nurse anticipate after the client receives the albumin? 1.) Venous stasis and blood urea nitrogen level 2.) Ascites and blood ammonia levels 3.) Peripheral edema and hematocrit level 4.) Capillary perfusion and blood pressure

3

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites? 1.) Portal hypotension 2.) Kidney malfunction 3.) Diminished plasma protein level 4.) Decreased production of potassium

3

A school health nurse is teaching a health class of 12-year-olds about hepatitis C. Which statement by a student indicates an understanding of the origin of the disease? 1.) "people working at restaurants can give it to you if they don't wash their hands." 2.) "you're more likely to get it in crowded living conditions." 3.) "you can catch it while you're getting a tattoo." 4.) "the disease is passed from person to person by causal contact."

3

An 80-year-old client is brought to the emergency department by their daughter. The client has a history of Alzheimer's dementia. The daughter is concerned because he is not eating and drinking well. Based on the table below, what is the priority intervention? Vital signs: Temperature 98.9 Heart rate 110 Respirations 24 Blood pressure 98/56 Oxygen saturation 94 on Room air Assessment Oriented to person Skin warm and dry, flaky Poor skin turgor lungs clear to auscultation No edema Labs Sodium 150 mEq/L Potassium 4.8 mEq/L BUN 38 creatinine 1.2 A. Request a dietary consult. B. Place the client on the heart monitor. C. Administer the ordered IVF of LR at 100 ml/hr. D. Administer PRN albuterol by metered-dose inhaler

3

At 1 am a 28-month-old toddler is admitted to the pediatric unit with suspected meningitis. At 3 am, after the child is settled in, the mother tells the nurse, "I have to leave now, but whenever I try to go my child gets upset and then I start to cry." What is the best action by the nurse? 1. Walking the mother to the elevator 2. Encouraging the mother to spend the night 3. Staying with the child while the mother leaves 4. Telling the mother to wait until the child falls asleep

3

The nurse cares for a client with atrial fibrillation and a heart rate of 123 beats/min. How does the heart rate affect cardiac output for this client? 1. Ventricular filling time increases 2. Stroke volume increases 3. Ventriculare filling time decreases 4. Oxygen demand decreases

3

a 2-year-old toddler is admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the most important safety measure for the nurse to institute immediately after the child has a seizure? 1. Monitoring the child's vital signs 2. Padding the side rails of the toddler's crib 3. Placing the child in the side-lying position 4. Bringing suction equipment to the bedside

3

The health care provider prescribes donepezil (Aricept) 5 mg by mouth once a day for a client exhibiting initial signs of dementia of the Alzheimer type. The client is already taking digoxin (Lanoxin) 0.125 mg in the morning and alprazolam (Xanax) 0.5 mg twice a day. What should the nurse teach the client's spouse to do? A. Remind the spouse in the morning which medications must be taken during the day. B. Provide the spouse with the medications at the appropriate times they should be taken. C. Prefill a weekly drug box that has separate sections for different times for the spouse to self-administer. D. Hang a list of medications with the times at which the spouse should take them.

3 Clients with early dementia of the Alzheimer type usually have some short-term memory loss. A prefilled box of medications eliminates the need to determine what drugs need to be taken. Also, it provides the spouse with objective proof that the medications have or have not been taken.

A nurse cares for a client suspected of having acute respiratory distress syndrome (ARDS). Which assessment data supports the suspected diagnosis? Select all that apply. A. Slow onset B. Metabolic alkalosis C. Confusion D. Tachypnea E. Use of accessory muscles.

3,4,5

A nurse plans to teach a 7-year-old child with recently diagnosed type 1 diabetes how to give insulin injections. What should be included in the first lesson? Select all that apply. 1.) Inviting the child's friends to participate in the lesson 2.) Offering a booklet to read at home 3.) Seeking a return demonstration of how to give an injection to a doll 4.) Providing a syringe for the child to practice manipulating 5.) Explaining why insulin is needed

3,4,5

The nurse is caring for a client with cellulitis in the left leg. The client is found to have MRSA in the wound. What should the nurse include when caring for the client in isolation for MRSA? 1. Surgical mask 2. Shoe covers 3. Hand hygiene 4. Sterile gloves when entering the room 5. Gown

3,5

A 10-year-old girl with diabetes joins the school's soccer team. Her mother is unsure whether to tell the coach of her child's condition. The mother asks the school nurse for guidance. On what information should the nurse base the response? 1.) The coach might violate confidentiality by discussing the child's condition with other faculty members 2.) The school nurse will treat the child if clinical findings of hypoglycemia are recognized early 3.) Children may have to leave athletic teams if school authorities learn that they have diabetes 4.) Children with diabetes who participate in active sports can have episodes of hypoglycemia

4

A 76-year-old client is admitted to the ICU. Based on the information below, identify the priority nursing intervention. Vital signs: Temperature 99.9 degrees F Heart rate of 118 beats per minute Respirations 22 breaths per minute Blood pressure 92/40 Oxygen saturation 95% on room air Labs: WBC 14.4 Hemoglobin 13 Hematocrit 36% Platelets 150 Sodium 150 Potassium 4.9 BUN 28 Creatinine 2.3 Glucose 758 Assessment: Oriented but lethargic Mucous membranes dry Scant urine output- urine cloudy and foul smelling Lungs clear to auscultation 1.) Administer Ceftriaxone IVPB 2.) Administer D50 IVP 3.) Administer Regular Insulin IVP 4.) Administer NS at 175 ml/hr

4

A child is diagnosed with hepatitis A. The client's parent expresses concern that the other members of the family may get hepatitis because they all share the same bathroom. The nurse's best reply is: 1.) "Your child may use the bathroom, but you need to use disposable toilet covers." 2.) "You will need to clean the bathroom from top to bottom every time a family member uses it." 3.) "I suggest that you buy a commode exclusively for your child's use." 4.) "All family members, including your child, need to wash their hands after using the bathroom ."

4

A client diagnosed with viral hepatitis develops liver failure and hepatic encephalopathy. Which of these measures should the nurse healthcare provider include in this client's plan of care? 1.) weigh once a week 2.) provide high-protein feedings 3.) institute droplet precautions 4.) monitor the blood glucose

4

A client is diagnosed with primary hypertension. When taking the client's history, the healthcare provider anticipates the client will report which of the following.? 1. Every once in a while I wake up covered in sweat 2. I'm starting to get out of breath when I climb a flight of stairs 3. Sometimes I get pain in my lower legs when I take my daily walks 4. I have not noticed any significant changes in my health

4

A client is on a ventilator. A nurse asks another nurse, "What should be done when condensation resulting from humidity collects in the ventilator tubing?" What is the nurse's best response? A. "Document the output on the record." B. "Notify the respiratory therapist." C. "Decrease the amount of humidity." D. "Empty the fluid from the tubing."

4

A client with a coronary occlusion is experiencing chest pain and distress. The nurse administers oxygen to: 1. Prevent cyanosis 2. Increase oxygen tension in the circulating blood 3. Prevent dyspnea 4. Increase oxygen concentration to heart cells

4

A client with a diagnosis of dementia of the Alzheimer type has been taking donepezil 10 mg/day for 3 months. The client's partner calls the clinic and reports, "He's gotten more restless and agitated, and now he's nauseated." What should the nurse advise the partner to do? A. Administer the medication to the partner at bedtime. B. Omit one dose today and start with a lower dose tomorrow. C. Give the medication with food. D. Bring the partner to the clinic for testing and a physical examination.

4

A client with myasthenia gravis improves and is discharged from the hospital. Discharge medications include pyridostigmine (Mestinon) 10 mg orally every six hours. The nurse evaluates that the drug regimen is understood when the client says, "I should: 1.) "drink milk with each dose of mestinon" 2.) "take the mestinon on an empty stomach" 3.) "count my pulse before taking the drug" 4.) "set my alarm clock to take my medication"

4

A client with type 1 diabetes is transported via ambulance to the emergency department of the hospital. The client has drum hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing? 1.) Dawn phenomenon 2.) Hypoglycemic reaction 3.) Hyperosmolar nonketotic coma 4.) Ketoacidosis

4

A health care provider schedules a paracentesis for a client with ascites. What should the nurse include in the client's teaching plan? 1.) Maintain a supine position during the procedure 2.) Stay on a liquid diet for 24 hours after the procedure 3.) consume a diet low in fat for three days before the procedure 4.) Empty the bladder immediately before the procedure

4

A nurse assesses a client who is recovering from a thoracentesis. Which assessment finding is most concerning to the nurse? 1. Expiratory wheezes in the upper and lower lobes 2. Respiratory rate of 25 breaths/min. 3. Heart rate 115 beats/min 4. Diminished breath sounds on the affected side

4

A nurse is performing an assessment on a client with type 2 diabetes. The nurse notes bilateral pedal capillary refill of 3-5 seconds. Which factor does the nurse recognize as contributing to this finding? 1.) The client's feet are likely cold, which can decrease capillary refill time 2.) A client with elevated blood glucose often has more viscous blood, which may slow capillary refill time 3.) Diabetic neuropathy is a common cause for decreased circulation and slow capillary refill 4.) Diabetes can cause damage to capillaries and other blood vessels, which may impede blood flow in the extremities

4

An 85-year-old client with a history of congestive heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sim's position, receiving oxygen at 2 L/min via nasal cannula. Which action would the nurse do first? 1. Call the primary health care provider immediately 2. Monitor the pulse oximeter to ascertain the oxygen level 3. Obtain the apical pulse and blood pressure 4. Raise the client to high-Fowler position

4

During the morning assessment of a client with cirrhosis, you note the client is disoriented to person and place. In addition, while assessing the upper extremities, the client's hands demonstrates a flapping motion. What lab results would explain these abnormal assessment findings? 1.) Creatinine level of 2.0 mg/dL 2.) Potassium level of 3.7 mol/L 3.) Calcium level of 10.9 mg/dL 4.) Ammonia level of 68 u/dL

4

The client with hypertension is being discharged on captopril and spironolactone. What priority discharge teaching should the nurse include? 1. Be sure to include foods high in potassium 2. Be sure to avoid eating grapefruit or drinking grapefruit juice 3. Take these medications with food 4. Be sure to avoid salt substitutes that contain potassium chloride

4

The nurse cares for a client with diabetes mellitus. The client's blood glucose level is 563 mg/dL upon admission. Which physical characteristic does the nurse expect to assess? 1.) The client exhibits tremors 2.) The client is diaphoretic 3.) The client reports tingling lips 4.) The client has poor skin turgor

4

The nurse is providing home care instructions to the client with cellulitis. Which statement, if made by the client, should concern the nurse? 1. I will keep my affected leg elevated to keep swelling down 2. I will be sure to get enough rest and stay off my affected leg 3. I will keep all follow-up appointments with my healthcare provider 4. I will take my antibiotics until the affected area looks less red

4

The physician orders Lactulose 30 mL by mouth three times a day for a client with cirrhosis. What findings below demonstrates the medication is working effectively? 1.) Decreased albumin levels 2.) Presence of asterixis 3.) Absence of fruity breath 4.) Improvement in level of consciousness

4

Two hours after a cardiac catheterization that was accessed through the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? 1. Take the client's blood pressure 2. Recognize the response is expected 3. Call the health care provider 4. Check the client's pedal pulses

4

What lab results does the nurse expect when clients develop respiratory alkalosis? A. A decreased pH, decreased Pco2 B. An elevated pH, elevated Pco2 C. A decreased pH, elevated Pco2 D. An elevated pH, decreased Pco2

4

a 2.5 year old toddler is admitted with a fever of 103 F (39.4 C), stiffness of the neck, and general malaise. The diagnosis is acute bacterial meningitis. What is the priority nursing intervention for this child? 1. Administering PRN Acetaminophen 2. Increasing fluids 3. Administering oxygen 4. Instituting droplet precautions

4

A client is admitted to the hospital and is found to have the following arterial blood gas results: pH 7.30, Po2 60 mm Hg, Pco2 55 mm Hg, and HCO3 23 mEq/L. What is the priority nursing intervention? 1. Apply oxygen 2. Initiate cardiac monitoring 3. Administer sodium bicarbonate 4. Administer insulin

1

The nurse is caring for a client with diabetes. Which task can be delegated to the UAP? 1.) Assess the client's feet for skin breakdown 2.) Educate the client on self-monitoring blood glucose 3.) Obtain a blood glucose by finger stick 4.) Answer questions on signs and symptoms of hypoglycemia

3

A client is admitted with heart failure. Which lab value supports this diagnosis? 1. Elevated troponin I 2. Increased creatinine kinase 3. Decreased C-reactive protein 4. An elevated brain natriuretic peptide

4

A client with cellulitis of the leg asks why bed rest has been prescribed. The nurse explains that the primary purpose of bed rest for this client it to: 1. Decrease catabolism to promote healing at the site of injury 2. Lower the metabolic rate in an attempt to help reduce the fever 3. Reduce the energy demands on the body in the presence of infection 4. Limit muscle contractions that may force causative organisms into the bloodstream

4

Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit? 1. pH 7.31, CO2 43 mm Hg, HCO3- 30 mEq/L 2. pH 7.32, CO2 34 mm Hg, HCO3- 24 mEq/L 3. pH 7.28, CO2 50 mm Hg, HCO3- 23 mEq/L 4. pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L

4 A client in diabetic ketoacidosis will have blood gas readings that indicate metabolic acidosis. The pH will be acidic (7.30), and the HCO 3 - will be low (20 mEq/L [20 mmol/L]). The normal pH is 7.35 to 7.45; CO 2 ranges from 35 to 45 mm Hg, and HCO 3 - ranges from 22 to 26 (22 to 26 mmol/L). A pH of 7.35 and a CO 2 of 47 mm Hg indicate respiratory acidosis. pH values of 7.46 and 7.50 represent alkalosis, not acidosis.